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OPTUM PHARMACY 702, LLC
DSH090004 Georgetown University Hospital
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Covered Entity Details
Entity Name
Georgetown University Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH090004
Entity Address
3800 Reservoir Road, NW
Washington, DC 20007
Medicare Provider Number
090004
Participating Start Date
4/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
1/19/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David C Ho, VP of Finance
(202) 444-4724
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2022
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